Grievances and Appeals

If you have a problem with your health plan, care, provider, or services, you can file a complaint with the plan at any time. This is called a Grievance.

A grievance is any expression of dissatisfaction regarding your healthcare services. You, or someone you designate, can file a grievance either by phone or in writing. Delaware First Health is available to assist you with completing the necessary forms to file a grievance or appeal.

Examples of grievances include:

• Wait time to see a doctor
• Being treated unfairly by office staff
• Unclean facilities

If you get a letter saying something was denied, stopped, or reduced, you can ask for an appeal. You can file a grievance or appeal by phone, email, mail, fax, or in person. You can ask for the grievance or appeal yourself or you can ask someone such as your doctor or family to request it for you.

We will send you a letter within five (5) business days, letting you know we received your grievance. If you need additional time to submit information about your grievance, you are allowed to ask us for a 14-day extension. We will extend the resolution of your grievance up to 14 days should we need additional time that is in your best interest. We will notify you in writing within 2 days of determining an extension is needed. Once we have completed the review of your grievance, we will send you a response in writing within 30 calendar days.  If you need help, please call our Member Services number they can help you.

To request an appeal or grievance you can:

• Call Member Services Toll Free at: 1-877-236-1341 (TTY: 711)
• Send it by fax to 1-833-525-0054
• Send a letter by mail to:

Delaware First Health
Appeals & Grievances
PO Box 10353
Van Nuys, CA 91410-0353

• For Behavioral Health Medical Necessity Criteria Appeals:

P.O. Box 10378
Van Nuys, CA 91410-0378

Fax number: 866-714-7991

• For Behavioral Health Claims Appeals:

Attn: Claims Department
P.O. Box 8001
Farmington, MO 63640-8001

We can provide translation or interpreter service if you need it.

You can find detailed information about grievances and appeals in our Member Handbook.

Written consent allows Delaware First Health to process the grievance with the member’s designated representative. It may involve the disclosure of protected health information (PHI) for the purpose of resolving the grievance. This consent does not authorize the representative to make healthcare decisions or access other PHI unless separately authorized.

Download the Grievance Written Consent Form (PDF)

Submission Options:

Fax:
833-525-0054
Member Portal
Mail:
Delaware First Health
ATTN: Appeals and Grievances
PO Box 10353
Van Nuys, CA 91410-03534